Emergency Medicine 101 Flashcards
Definition of syncope
sudden and transient LOC with loss of postural tone accompanied by rapid return to baseline
DDx for syncope
cardiac vs. non cardiac; cardiac: dysrhythmias, pacemaker issues, outflow obstruction (aortic stenosis, HOCM), MI, dissection, cardiomyopathy, PE; non-cardiac: reflex-mediated - vasovagal, orthostatic, situational, carotid massage/pressure, subclavian steal (arm exercises), medications (BB, CCB, digoxin, insulin; QT prolonging meds, drugs of abuse), focal CNS (hypoxia, epilepsy, dysfunctional brainstem)
Physical exam for syncope
cardiac + neuro
Investigation for syncope
ECG, CBC, lytes, extended, lytes, glucose, troponin, Cr,
Cardiac dysrhythmias associated with syncope
WPW, Brugada, heart block, QT prolongation, ARVD, HOCM
MGMT of syncope
General (ABCs, monitors, oxygen, IV access), cardio consult vs outpt cardiac, canadian syncope risk score
Definition of altered LOC
decreased LOC caused by CNS dysfunction (primary CNS vs. diffuse)
DDx of altered LOC
drugs: abuse - opiates benzos, BBs, TCA, ASA, acetaminophen, digoxin; environmental: carbon monoxide, cyanide; infectious: sepsis, meningitis/encephalitis, cerebral abscess; metabolic: hypogylcemia, electrolytes, uremia, kidney failure, hepatic encephalopathy, thyroid, DKA, HHS; structural: ICH, epidural hematoma, subdural hematoma, SAH, seizures, strokes, hydrocephalus, ACS, dissection, arrhythmias, shock
Physical exam for altered LOC
ABC, primary survey, temp and glucose, rapid neuro
Inv for altered LOC
CBC, lytes, glucose, Cr, urea, LFTs, INR/PTT, serum osmoles, VBG, troponin, tox screen; ECG, CXR, CT Head
MGMT for altered LOC
general, universal antidotes (oxygen, glucose, naloxine, thamine), ABx, BP control; dispo: admit for work-up
Migraine HA definition
“POUND” - pulsatile, onset of 4 - 72 hours, unilateral, N/V, disabling; photophobia/phonophobia, chronic, recurrent, +/- aura
Cluster HA definition
unilateral sudden sharp retro-orbital pain, < 3 hours, usually at night, pseudo-Horner’s, associated with smoking and alcohol
Tension HA definition
tight bandlike, tense neck and scalp, associated with stress/sleep
DDx for HA
primary (migraines, cluster, tension) vs. secondary: intracranial - bleed (epidural, subdural, SAH, intracerebral), infectious: meningitis, encephalitis, brain abscess; increased ICP (mass, cerebral venous sinus thrombosis); extra-cranial: AACG, temporal arteritis, carotid artery dissection, carbon monoxide poisoning
Red Flags for headaches
sudden onset, thunderclap, exertional, meningismus, fever, neurological deficit, AMS, ICP signs
Physical for HA
neuro, neck, eye exam
Investigation for HA
CT Head, LP if CT head negative but suspicious, ESR/CRP if temporal arteritis
MGMT for HAs (benign)
fluids, metoclopramide 10 mg IV, analgesic, ketorolac, steroids (dex 10 mg IV); sumatriptans, magnesium, ketamine, propofol
Abdo Pain DDx
RUQ: hepatitis, biliary disease, pancreatitis, lung (PNA, PE, pleural effusion), Epigastrium: PUD, gastritis, pancreatitis, ACS; LUQ: pancreatitis, gastritis, PNA/pleural effusion/PE; R flank: kidney, colitis, AAA**; umbilicus: colitis, perforation, obstruction, AD, AAA; L flank: colitis, perforation, obstruction renal colic, pyelonephritis, AAA; RLQ: appendicitis, ectopic, PID/TOA, testicular torsion/epididymytis, orchitis, ovarian torsion, renal colic; hypogastric: UTI, renal colic; LLQ: diverlitulicis, ectopic, PID, TOA, testicular torsion, epididymitis, orchitis, ovarian torsion, renal colic
Can’t Miss Diagnoses for abdo pain
ectopic, ruptured AAA, pancreatitis, cholangitis, mesenteric ischemia, obstruction, perforated viscus, complicated diverticulitis
Inv for abdo pain
CBC, lytes, Cr, LFT, lipase, lactate, BHCG; abdo ultrasoound/CT, CXR, ECG as needed
MGMT for abdo pain
ABCs, NPO, analgesia, consult surgery PRN
Pelvic Pain DDx
ruptured cyst, ovarian abscess, ovarian torsion, saplingitis, tubal abscess, hydrosalpinx, PID, endometriosis, fibroids; ectopic, threatened abortion, ovarian hyperstimulation; 2nd trimester: placental abruption, round ligament pain, braxton-hicks contraction; bartholin abscess; urinary
Inv for pelvic pain
CBC, lytes, BHCG, +/- swabs; urine, bedside ultrasound
MGMT for PID
if severe, admit with IV ABx (cefoxitin 2g IV q6h + doxycycline 100 mg IV q12 x2, then PO); mid-moderate - ceftriaxone 250 IM x1 and doxy 100 mg BID x 14 days
DDx for back pain
cauda equina, SCC (spinal mets, epidural abscess, disc hernation, spinal fracture with subluxation), meningitis, vertebral osteomyelitis, transverse myelitis); vascular - AD, ruptured AAA, PE, MI
Red Flags for backpain
bowel and bladder dysfunction, anaesthesia, constitutional symptoms, chronic disease, paraesthesia, age > 50, IVDU/infection, neurological deficits
Physical Exam for back pain
vitals, pulse deficity, skin for infection/trauma, abdo for AAA, cardiac exam (murmur), MSK, neuro, PVR!
Inv for back pain
CBC + ESR/CRP if infectious; bedside ultrasound, PVR (> 200 cc has sensitivity of 90% for CES)
MGMT for Cauda Equina syndrome
urgent MRI, spine consult, analgesia, IV dex
MGMT for AD
resuscitation, IV labetalol
MGMT for epidural abscess/vertebral osteomyelitis
MRI, IV Abx, ortho
Definition of anaphylaxis
life-threatening immune hypersensitivity systemic reaction leading to histamine release, vascular permeability and vasodilation
Common triggers for anaphylaxis
foods (egg, nut, mlk, fruits), meds, insect bites, aeroallergens
DDx for anaphylaxis
shock, angioedema, flush syndrome, asthma exacerbation, red man syndrome
Diagnostic Criteria for Anaphylaxis
acute onset (mins-hours) + any of: 1. skin+/-mucsa + respiratory/low BP; 2. exposure to likely allergen(2/4) - skin-mucosal involvement, respiratory difficulties, low BP, GI symptoms 3. low BP after exposure to known allergies
Red Man Syndrome
anaphylactoid reaction by rapid infusion of vancomycin –> erythematous rash to face, neck, upper torso;
Definition of asthma
chronic inflammatory airway disease with reversible episodes of bronchospasm and variable airflow obstruction
Triggers for asthma
URTI, allergens, smoking, exercise
Classification of asthma: mild, moderate, severe
mild: >95%, SOBOe, chest tightness, expiratory wheeze, FEV1 > 60% predicted; Moderate: SOB at rest, cough, congestion, nocturnal symptoms, >95%, expiratory wheezing, FEV1 40 - 60; severe: agitated, diaphoretic, labored breathing, difficulty speaking; vitals: high HR, high BP, O2 < 95%; exp and inspiratory wheezing, FEV1 < 40%
Definition of good asthma control
daytime symptoms < 2x/week, no activity limitations, no nocturnal symptoms, rescue puffer < 2/week, normal PFT
MGMT of asthma
atrovent 0.5 m neb or 4 - 8 puffs q20 mins x 3; ventolin 5 mg neb or 4- 8 puffs via MDI spacer q20mins x 3, prednisone 50 mg PO
MGMT of severe asthma
2g MgSO2 over 30 mins, epi 0.3 mg IM then 5 mcg/min IV infusion, ketamine with BiPAP, intubate with ketamine + succinylcholine
COPD RFs
smoking, occupational, chemical exposure
COPD triggers
URTI, pneumonia, allergens, polluntants, smoking, CHF, PE, MI
COPD Sx
increasing SOB, sputum production, sputum purulence
COPD signs of severity
rapid shallow pursed lip breathing, use of accessory muscles, paradxical chest wall movement, central cyanosis, hemodynamic instability
MGMT COPD
salbutamol 5 mg nes or 4 - 8 puffs MDI q15 mins x 3 PRN; atrovent 0.5 mg nebs or 4 - 8 puffs q15-20mins x 3; steroids: oral prednisone 40 - 60 mg for 5 - 10 days, antibiotics ot 2+ (sputum production/purulence/SOB) like amox, or cephalosporin, CPAP or BiPAP
MI Definition
myocardial ischemia on spectrum of ACS; diagnosed with cardiac marker abnormalities and 1 of ECG changes, history consistent with ACS
Stable Angina definition
known history of angina; transient episode of chest discomfort secondary to ischemia precipitated by exertion/emotion, < 15mins, relieved by rest or nitro
Unstable Angina definition
angina with minimal exertion or at trest or new onset angina or angina post PCI/MI/CABG; worsening change from baseline anginal symptoms, increased duration of pain or threshold, or decreased response of typically effective angina medications
STEMI definition
ST elevation of 1+ mm/in 2 contiguous leads; V1-V3: 1.5 mm for F, 2.0 for M > 40, 2.5 for M < 40
MGMT of STEMI
ASA 162 - 325 mg chewed, clopidogrel 300 mg PO or ticagrelor 180 mg PO, antithrombotic: UFH 4000U then 12U/kg, fibrinolytics (enoxaparin); PCI within 90 mins of hospital arrival; lytics < 12 hours of symptoms
CHF etiology
CAD, HTN, valvular disease, cardiomyopathy, infarction, pericardial disease, myocarditis, cardiac tamponade, metabolic disorder, toxins, congenital
CHF triggers
cardiac (ischemia, arrhythmias), high CO (anemia, infection, pregnancy, hyperthyroidism), medications (forgot meds, negative inotropes, steroids, NSAIDs), lifestyle (high salt, renal failure, PE, HTN)
L-sided symptoms + signs of HF
SOB, orthopnea, PND, nocturia, fatigue, altered mental status, pulmoary congestion; hypoxia, crackles, wheezes, S3-S4
R-sided symptoms + signs of HF
fatigue, abdominal distension, swelling, weight gain; Sx: pitting edema, JVP elevation, hepatosplenomegaly, ascites
Inv for HF
CBC, lytes, AST, ALT, BUN, Cr, Troponin, BNP, CXR, ECG, POCUS
MGMT of HF
General, NG 0.4 mg SL q5 mins (if sBP > 100) +/- topical NG patch (0.2 - 0.8 mg/h), furosemide (double home dose); second-line: NTG infusion (10 mcg/min and titrate), if hypotensive, norepi 2 - 12 mcg/min or dobutamine 2.5 mcg/kg/min
Causes of Dysrhythmias
toxins, ischemia, electrolytes, physical activity (post MI reperfusion), genetic (re-entry)
Types of Bradydysrhythmias
primary = prolonged PR interval; Mobitz I = gradual PR increase then QRS drop; Mobitz II = PR interval constant with QRS drop; complete = p and QRS are unrelated, constant intervals
Types of SVTs
Regular: sinus tachycardia, atrial tachycardia, atrial flutter, SVT (AVNRT > AVRT), junctional tachycardia; irregular: a.fib, multifocal atrial tachycardia, SVT with aberrancy
Types of ventricular tachydysrhythmias
regular: Vtach, SVT with aberrancy; irregular: VFib, polymorphic VT AFib with WPW
MGMT for unstable bradycardia
atropine 0.5 IV bolus q3-5mis x 6; +/- infusion of dopamine 2 - 10 mcg/kg/min or epi 2-10 mcg/min; transcutaneous pacing if second degree or higher
MGMT for unstable tachycardia
synchronized cardioversion
MGMT of unstable AFib/AFlutter
synchronized cardioversion
MGMT of unstable VF/pVT
epinephrine 1 mg IV q3-5 mins with CPR shocks, amiodarone 300 mg IV bolus with 2nd dose of 150 mg IV
ruptured AAA RFs
smoking, hypertension, CAD, CTD, DM, FHx
Classic triad of AAArupture
pulsatile mass, hypotension, acute onset back/abdo/flank pain
presentations associated with AAA
syncope, UGIB, LGIB, high output HF, ureteral colic, bowel obstruction symptoms
Inv for AAA
POCUS, ECG, CTA (for stable patients)
MGMT for AAA
general, resuscitation - aim for sBP of 90 - 100, massive transfusion protocol, urgent surgical intervention
Post-op complications of AAA
Infection: graft contamination/seeding; Ischemia (spinal cord ischemia, CVA, visceral ischemia), aortoenteric fistula (GI bleeding), endoleak (blood flow outside of graft lumen)
Definition of Acute Arterial Occlusion
acute emboli or thrombosis causing true emergency due to irreversible damage within 6 -8 hours
RFs for acute arterial occlusion
atherosclerosis, MI with LV thrombus, AFib, valve stenosis, stents/grafts
Signs for Acute Arterial Occlusion
6Ps - pain, paresthesia, pallor, polar, pulselessness, paralysis
Tests for Acute Arterial Occlusion
doppler probe to leg with proximal BP cuff; perfusion pressure < 50 mmHG or ABI < 0.5
How to measure ankle brachial index
sBP using doppler of DP/PT arteries / brachial arteries (whichever is highest from both arms)
MGMT of acute arterial occlusion
immediate heparinization with 5000 IU bolus; revacularization vs CT angio
normal ABI
> 0.9; < 0.5 is severe PAD
Well’s Criteria for DVT
1 point for any of: active cancer, paralysis/paresis/immobilization of lower limb, bedridden > 3 days or major surgery in 3 months, tenderness along DV system, entire leg swollen, cald swelling > 3 cm, pitting edema on symptomatic leg, previous DVT; -2 if alternative diagnosis; DVT unlikely if 1 or less
DVT cut-off for Well’s
1 or less: unlikely; 2+: likely; if unlikely, order d-dimer; if DVT likely, order leg doppler
Wells Criteria for PE
3: for signs and symptoms of DVT, PE is #1 diagnosis 1.5: for tachycardia, immobilization > 3 days or surgery in last month, Hx of DVT/PE, 1: hemoptysis, active cancer
Wells Criteria cut-off
0 - 4 points: low risk; 4+: high risk; if <4 - order d-dimer, otherwise get CTPA
PERC rules qualifiers
low-risk patient and low pre-test probability = < 2 % chance of PE; if < 50 yo, HR < 100, SpO2 < 95%, no hemoptysis, no estrogen use, no history of surgery/trauma, no hx of DVT/PE, no signs of DVT
PE or DVT MGMT
LMWH, DOAC, thrombolysis if unstable/resusication
GI bleeding RFs
mediations (NSAIDs, anticoagulants), excessive vomiting, bleeding disorder, malignancy, alcohol use, ulcer hx, H.pylori
UGIB DDx
peptic ulcer disease (gastric > duodenal), gastritis/esophagitis, MW tears, gastric CA
LGIB DDx
colitis (infectious, ischemic, inflammatory), anorectal pathology, angiodysplasia, diverticulosis, malignancy
